Development of an Educational Plan with Compassion Fatigue ... · Compassion Fatigue Awareness...

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Development of an Educational Plan with Compassion Fatigue Preventive Strategies for Registered Nurses By Phyllis J. Dykes RN, BSN, PHN A Project presented to the FACULTY OF THE SCHOOL OF NURSING POINT LOMA NAZARENE UNIVERSITY in partial fulfillment of the requirements for the degree MASTER OF SCIENCE IN NURSING JULY 2013 Larry B. Rankin, PhD, RN, CNE, Chair Christine Sloan, RN, MSN, CNS, CPON, Member

Transcript of Development of an Educational Plan with Compassion Fatigue ... · Compassion Fatigue Awareness...

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Development of an Educational Plan with Compassion Fatigue Preventive Strategies for

Registered Nurses

By

Phyllis J. Dykes RN, BSN, PHN

A Project presented to the

FACULTY OF THE SCHOOL OF NURSING

POINT LOMA NAZARENE UNIVERSITY

in partial fulfillment of the requirements for the degree

MASTER OF SCIENCE IN NURSING

JULY 2013

Larry B. Rankin, PhD, RN, CNE, Chair

Christine Sloan, RN, MSN, CNS, CPON, Member

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POINT LOMA NAZARENE UNIVERSITY

School of Nursing

Master of Science in Nursing

NAME OF STUDENT: Phyllis J. Dykes RN, BSN, PHN

TITLE OF PROJECT: Development of an Educational Plan with Compassion

Fatigue Preventive Strategies for Registered Nurses

COMMITTEE:

_____________________________________________

Larry B. Rankin, PhD, RN, CNE, Chair Date

_____________________________________________

Christine Sloan, RN, MSN, CNS, CPON, Member Date

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Abstract

Compassion fatigue in the nursing profession can be detrimental to individual nurses as

well as health care organizations. Nurses that are victims of compassion fatigue may

experience a plethora of medical and mental health conditions and nurses working with

traumatized and suffering patients may start to relive the patients’ stress and anxiety.

Health care organizations are affected by compassion fatigue as employees call in sick

and experience conflict and lack of teamwork and nursing staff resist necessary changes.

The primary purpose of this project is to review the current evidence on compassion

fatigue preventive strategies and to develop an educational plan for registered nurses. The

specific objective is to produce an educational film based on two of the Standards of Self

Care Guidelines set forth by the Green Cross Academy of Traumatology: 1) health care

providers must do no harm to themselves while caring for others, and 2) health care

providers have a responsibility to take care of their own physical, social, emotional, and

spiritual selves.

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Acknowledgements

I would like to thank the Lord for all of the blessings He has bestowed upon me and

my family. I also would like to thank the U.S. Navy Nurse Corps for allowing me the

privilege of attending graduate school at Point Loma Nazarene University.

Thank you to my mother, Connie Hill, Joe, Aunt Katie, Steve and Shannon Biggs, my

sister, Tesha, and all of my friends and family for your encouraging words and motivation to

complete my studies. I also would like to thank the Watsons for all of their support. Most of

all, thank you to my husband, Mark, for helping with our infant (and now toddler) son,

Logan. I would not have been able to complete this program without you. Thank you Lord

for Logan, who melts my heart every time he smiles at me.

To all of my professors—Dr. Son Chae Kim, Dr. Larry Rankin, Dr. Jeanne Maiden,

Professor Amanda Thurman, Professor Jane Rabun, Professor Matt Boyne, Dr. Ray Posey,

Dr. Michelle Riingen, Dr. Dee Oliveri, Professor Mary Margaret Rowe, Dr. Barbara Taylor,

and Dr. Angelica Almonte—thank you for sharing your knowledge. And thanks to my

clinical preceptors, Dr. Roger Strong, Dr. Kris Lambert, Professor Chris Sloan, Mr. Keynan

Hobbs, and Dr. Susan McDonald; I feel so blessed to have been mentored by such amazing

people. I wish the program lasted four years, so I could learn even more from all of you.

Thanks to Dr. Kris Lambert for being my mentor and encouraging me to work on a project I

am so passionate about, and thanks to Dr. Rankin for being such a supportive advisor.

Thank you Carly Lambert, the creative genius behind the camera, and all the actors in

my educational film—Amanda, Chelsea, Aunt Katie, Uncle John, and Keynan Hobbs—you

all did an amazing job.

Finally, thank you Lord for blessing me with the best two years of my life! And

thanks to my classmates for all the memories. I will really miss seeing you every week.

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Table of Contents

Chapter One: Introduction ....................................................................................... 1

Background .................................................................................................. 1

Significance of the Problem ......................................................................... 2

Effects on Nursing ........................................................................... 3

Effects on Patient Care ..................................................................... 4

Effects on Organizations................................................................... 4

Clinical Practice Guidelines ......................................................................... 5

Statement of the Problem ............................................................................. 6

Statement of the Purpose ............................................................................. 7

Chapter Two: Review of Literature ......................................................................... 8

Summary ...................................................................................................... 15

Conceptual Framework ................................................................................ 15

Chapter Three: Methodology ................................................................................... 17

Program Development ................................................................................. 17

Needs Assessment ........................................................................................ 19

Student Learning Outcomes ......................................................................... 19

Anticipatory Set ........................................................................................... 20

Instructional Strategies ................................................................................. 20

Program Delivery ......................................................................................... 21

Chapter Four: Evaluation ......................................................................................... 23

Evaluation Framework ................................................................................. 23

Assessment ................................................................................................... 25

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Evaluation .................................................................................................... 25

Chapter Five: Discussion ......................................................................................... 27

Global Effects .............................................................................................. 27

Program Significance ................................................................................... 29

Study Limitations ......................................................................................... 30

Conclusion ................................................................................................... 30

References ................................................................................................................ 32

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List of Tables

Table 1: Evidence Summary Grid............................................................................. 10

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List of Appendices

Appendix A: Project Film Outline............................................................................ 40

Appendix B: A Day in the Life of a Registered Nurse ............................................ 50

Appendix C: Compassion Fatigue Prevention Strategies for Registered Nurses .... 56

Appendix D: Training Critique Form ...................................................................... 58

Appendix E: Assessment of Student Learning: One-Minute Paper ......................... 60

Appendix F: Compassion Fatigue Prevention Strategies for

Registered Nurses Post-Test .............................................................. 61

Appendix G: MSN Project Film Permission Slip .................................................... 62

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 1

CHAPTER ONE

Introduction

There is a Native American wisdom warning that healers who heal again, and

again, will eventually need healing themselves (Stebnicki, 2008). This teaching can easily

be applied to the profession of nursing, which has been overwhelmed with professional

stressors that may in turn be precursors to nursing burnout and compassion fatigue.

According to Livingston (2011), nurses encounter five main categories of

professional stressors: direct patient care, physical work environment, interpersonal

conflict, administration issues, and inadequate knowledge. Nurses may also have adverse

outcomes due to work-related stress, such as difficulties in marriage, substance abuse,

medical co-morbidities, and mental health problems.

Empathy and compassion do not come without a cost; compassion fatigue inhibits

health care providers’ ability to deal with suffering patients (Figley, 2002). The

Compassion Fatigue Awareness Project lists symptoms of compassion fatigue as self-

isolation, substance abuse, inadequate self-care, nightmares, apathy, excessive blaming,

medical problems, compulsive behavior, and an inability to find pleasure in activities

(Smith, 2010).

Background

Compassion fatigue is a state of captivation with traumatized patients that leads to

health care providers vicariously reliving patient traumas (Figley, 1995). Compassion

fatigue affects cognitive function, emotions, behavior, spirituality, and can cause somatic

conditions. Health care workers can suffer from compassion fatigue and burnout

simultaneously. Early burnout symptoms can be minor, such as colds, overtiredness, and

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 2

a feeling of lack of achievement. Over time, burnout can lead to more serious effects such

as bitterness, somatic complaints, self-isolation, fatigue, and a numbness of emotion

(Portnoy, 2011). Compassion fatigue is similar to burnout, but the symptoms appear

instantaneously and are more prevalent than in burnout. Compassion fatigue becomes

apparent unexpectedly and causes a sense of despair and bewilderment (Potter et al.,

2010).

Nurses with burnout exhibit a reduction in empathy, whereas nurses with

compassion fatigue are overwhelmed with empathy (Stevens-Guille, 2003). According to

Figley & Figley (2007), one way to determine if a person is suffering from compassion

fatigue or burnout is to ask this simple question: “Do you love your work?” Individuals

answering “yes” may have compassion fatigue; those who answer “no” may be suffering

from burnout.

Criteria for a diagnosis of compassion fatigue include the presence of one or all of

the following symptoms: re-experiencing traumatic events, avoidance or numbness of

reminders of the traumatic event, and persistent arousal (Baranowsky & Gentry, 2011).

Significance of the Problem

Most nurses enter the profession to provide nurturing care to patients that are

traumatized or suffering. While the nursing profession has become technologically

driven, without compassion and empathy patients will not feel cared for (Lombardo &

Eyre, 2011). Compassion fatigue is a disorder that can affect registered nurses working in

virtually any patient care specialty. Nurses in all patient care specialties provide

passionate care and attend to patients’ physical, emotional, and spiritual needs

(Lombardo & Eyre, 2011), and because of their empathy for patients that are in pain or

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have undergone traumatic experiences, nurses are more susceptible to compassion fatigue

(Sabo, 2011).

Compassion fatigue is an important issue for health care organizations because of

the correlation of patient satisfaction, patient safety, and nurse retention (Collins & Long,

2003b). The American Association of Colleges of Nursing indicates that the United

States will encounter a nursing shortage of approximately 260,000 RNs by 2025

(Rosseter, 2011). If compassion fatigue is not addressed, the RN workforce may continue

to diminish (Potter, et al., 2010). If hospital administrators are made aware of compassion

fatigue prevalence in nurses, perhaps more preventive measures could be utilized,

resulting in better RN retention.

Effects on nursing. Nurses who work daily with suffering and traumatized patients

may become physically and emotionally drained over time. Operating room (OR) nurses

are at an increased risk for compassion fatigue because tasks need to be completed

extremely fast in order to save a patient’s life (Kendall, 1998); one moment they can be

in a calm, serene OR environment and the next, the patient’s blood is spilling onto the

floor. Emergency department nurses are also at high risk for compassion fatigue because

of the extremely stressful nature of their position of caring for patients experiencing

trauma, chronic obstructive pulmonary disease, heart attacks, and various other unstable

conditions (American Society of Registered Nurses [ASRN], 2007).

Although nurses in some specialties are at higher risk, all nurses are at risk for

compassion fatigue because they continuously witness patient suffering. The effects of

compassion fatigue can include decreased job performance and increased nursing

mistakes. Additionally, nursing morale and personal relationships decline as nurses’

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personal lives begin to degenerate (Kendall, 1998). Nurses with compassion fatigue may

experience personality changes, a decline in health or work performance, and a desire to

leave the nursing profession (Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010).

Effects on patient care. In order to deliver high quality patient care, nurses must

have outstanding leadership, adequate staffing, appropriate and genuine relationships

with providers, and a safe work environment (Van Bogaert, Meulemans, Clarke, &

Vermeyen, 2009). Improving nurses’ work environment will prevent nurse burnout and

compassion fatigue and increase patient satisfaction (Van Bogaert, et al., 2009).

Nurses with compassion fatigue are at greater risk for making medication errors

and spreading infection, and they may be unaware of potential patient safety risks (Drake,

Luna, Georges, & Steege, 2012). High patient satisfaction scores on hospital surveys

have coincided with high levels of nurse caring and compassion. Conversely, statistical

data revealing nurse burnout has been directly linked to patient dissatisfaction (Hooper et

al., 2010).

Effects on organizations. Compassion fatigue and burnout are leading factors in

the nation’s nursing shortage, as indicated by a 2007 study of the relationship between

nursing retention and nurse burnout (Erickson & Grove, 2007). Further, the research

indicated the nursing shortage is worsening due to an increase in patient co-morbidities

within the aging population and will continue to rise as more nurses are eligible for

retirement. It is reported that by 2020 the United States will have a shortage of 800,000

registered nurses (Erickson & Grove, 2007). Nurses under 30 years old were at highest

risk for burnout and were more likely to experience feelings of exhaustion,

discouragement, sadness, powerlessness, and fear (Erickson & Grove, 2007).

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Organizations that provide nurses with fair workloads, professional interpersonal

relationships, autonomy, and positive recognition have better nurse retention and

decreased nursing burnout and compassion fatigue (Van Bogaert, Meulemans, Clarke &

Vermeyen, 2009). Further, hospital administrators that provide a professional

organization for nurses to work in also have better nursing retention, which leads to high

quality patient care (Van Bogaert, et al., 2009).

Clinical Practice Guidelines

The clinical practice guidelines aimed at compassion fatigue prevention for

Department of Defense personnel are: 1) focusing on the positive impact of one’s work,

2) talking to colleagues for support, 3) setting boundaries for oneself, 4) maintaining

physical fitness, 5) reducing daily stressors, 6) avoiding comparisons to others, and 7)

maintaining patience with oneself (Defense Centers of Excellence, 2011). Boyle’s (2011)

recommendations for workplace interventions to reduce compassion fatigue for nursing

staff include on-site counseling, support groups for staff, de-briefing sessions, art therapy,

massage sessions, bereavement interventions, and provisions for nurses’ spiritual needs.

A 2002 case study discussed “Jane,” a female with compassion fatigue, a

restricted social support network, and considerable traumatic stress. Her treatment plan

consisted of self-soothing, stress management skills, social support through volunteer

work, cognitive-behavioral therapy, and desensitization to reduce traumatic stress. One

year after receiving treatment for compassion fatigue, Jane was thriving in her personal

life and work life (Figley, 2002).

According to the Standards of Self Care published by the Green Cross Academy

of Traumatology (GCAT), it is unethical to neglect self-care because acceptable self-care

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prevents harm to patients (GCAT, 2010). The GCAT’s Ethical Principles remind nurses,

or practitioners, of their responsibility to respect themselves, have a sense of dignity, and

be responsible for self-care. Finally, the group’s Standards of Humane Practice state that

every caregiver has a universal right to wellness, physical rest, emotional rest,

nourishment, and sustenance modulation. The effective tools for ongoing self-care are

assertiveness, stress reduction, interpersonal communication, cognitive restructuring, and

time management (GCAT, 2010).

The Traumatology Institute is a professional organization with a mission to

alleviate trauma around the world through research, education, and service. The Institute

provides an accelerated recovery program to assess, treat, and prevent compassion

fatigue. Treatment is available for nurses in a five-session protocol. Session One

incorporates assessment and evaluation, while Session Two is dedicated to establishing a

personal and professional timeline. During Session Three the nurse learns to reframe and

reprocess vicarious traumatic situations. Session Four is about supervising the self-

externalization and incorporates professional skills for the compassion fatigue student.

Session Five is geared towards closure and aftercare. Some of the major objectives for

compassion fatigue treatment are 1) understanding the hierarchy of events, 2) ensuring

self-care methodologies, 3) identifying available resources, 4) establishing patient

boundary-setting skills, and 5) learning eye movement de-sensitization and reprocessing

(Baranowsky & Gentry, 2011).

Statement of the Problem

Compassion fatigue in the nursing profession can be detrimental to individual

nurses as well as health care organizations. Nurses that are victims of compassion fatigue

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may experience a plethora of medical and mental health conditions and nurses working

with traumatized and suffering patients may start to relive the patients’ stress and anxiety

(Portnoy, 2011; Figley, 2002). Health care organizations are affected by compassion

fatigue due to employee sick calls, employee-employer conflict, lack of teamwork, and

nursing staff resisting necessary changes (Smith, 2010).

Statement of the Purpose

The primary purpose of this project is to review the current evidence on

compassion fatigue preventive strategies and to develop an educational plan for

registered nurses. The specific objective is to produce an educational film based on two

of the Standards of Self Care Guidelines set forth by the GCAT: 1) health care providers

must do no harm to themselves while caring for others, and 2) health care providers have

a responsibility to take care of their own physical, social, emotional, and spiritual selves

(2010).

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CHAPTER TWO

Review of Literature

In 1990, McMann and Pearlman coined the term vicarious traumatization to

explain the compassion felt by a clinician for a patient that survived a trauma (Craig &

Sprang, 2010). According to Coetzee & Klopper (2010), in 1992, Joinson described the

term compassion fatigue based on observations of emergency room nurses that no longer

had the ability to be compassionate. The term secondary traumatic stress disorder was

used in 1995 by Figley to describe the phenomenon of clinicians taking on symptoms of

post-traumatic stress disorder (Collins & Long, 2003a). Compassion fatigue, vicarious

traumatization, and secondary traumatic stress disorder are virtually interchangeable

terms (Collins & Long, 2003b); however, burnout is slightly different from compassion

fatigue as burnout is the progression of health care workers becoming worn down,

whereas compassion fatigue is an immediate sensation of feeling overwhelmed.

The literature was reviewed by investigating various medical and nursing journals

and the following databases: EBSCO Host, Academic Search Premier, MEDLINE,

CINAHL Plus with full text, Cochrane Database of Systematic Reviews, Health Source:

Nursing/Academic Edition, PsycINFO, and Military and Government Collection.

Keywords searched were compassion fatigue and mental health psychiatric nursing.

The initial search returned 1,838 articles but after revision of the search terms, the

results were narrowed to 847 articles published between 1944 and 2011. Because

compassion fatigue is a term that is only about 16 years old, the search was narrowed

again to studies conducted between 2000 and 2011 and returned 750 articles on October

4, 2011. Of these, 34 were saved to an Endnote library. However, the journal articles

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saved were regarding mental health and psychiatry as a combined entity and did not

pertain solely to psychiatric nursing. The other articles did not appear to focus on any

particular nursing specialty.

Out of the 34 journal articles obtained from October 4 to October 18, 2011, four

studies utilized instrumentation to measure compassion fatigue and/or burnout in

registered nurses. These studies were reviewed and placed in an evidence summary grid

(Table 1). The first article reviewed, “Predicting the Risk of Compassion Fatigue :A

Study of Hospice Nurses,” was conducted on the prevalence and the relationship between

nurse characteristics and compassion fatigue risk (Abendroth & Flannery, 2006). The

second article, “Positive and Negative Emotional Responses to Work-Related Trauma of

Intensive Care Nurses in Private Health Care Facilities,” reports on positive and negative

emotions experienced by Intensive Care Unit (ICU) nurses in East London. The study

was conducted to assess if the nursing staff was at risk for compassion fatigue or burnout

(Elkonin & van der Vyver, 2011). The third article, “Compassion Fatigue and Burnout,”

assessed compassion fatigue, compassion satisfaction, and burnout in inpatient and

outpatient nursing cancer units (Potter, et al., 2010). Finally, “Termination of Pregnancy

Services: Experiences of Gynaecological Nurses” tried to determine whether nurses

assisting with abortions, dilation, and curettage for elective and non-elective procedures

had an increased risk for compassion fatigue and burnout (Nicholson, Slade, & Fletcher,

2010). These studies were chosen because they utilized instrumentation to measure

burnout or compassion fatigue.

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Table 1

Evidence Summary Grid

Authors (year) And title of article.

Study design/ Purpose

Study setting/ Sample size

Instruments

Results Strengths & Limitations

Level of evidence

Abedroth& Flannery (2006). Predicting the Risk of Compassion Fatigue A study of nurses.

A non-experimental descriptive design using cross-sectional data and descriptive and inferential statistics to investigate the prevalence between nurse traits and compassion fatigue risk.

216 nurses from 22 hospices across the state of Florida

1). Demographic questionnaire developed by the researcher 2). Professional Quality of Life Compassion Satisfaction and Fatigue Subscales: Revision-III (ProQOL-CSF-R-III). 1). Professional Quality of Life Compassion Satisfaction and Fatigue Subscales: Revision-IV, 2). A biographical questionnaire 3). The Silencing Response Scale

-57 (26.4%) of the participants were in the high-risk category, 113 (52.3%) were at moderate risk, and 21.3% (n = 46) were at low risk for compassion fatigue.

Strengths - Demographics and work-related factors had minimal differentials in C.F. -37% response rate amongst participants. Limitations -Data collected on a one-time basis.

Level VI

Elkonin, D. van der Vyver, L. (2011) Positive and negative emotional responses to work related trauma of intensive care nurses in private health care facilities

Explore and describe the work-related positive and negative emotions experienced by ICU Nurses in private hospitals. Quantitative exploratory-descriptive design, and Qualitative data.

Three ICU’s with a total of 75 nurses in East London

1). ProQol Revision-IV, 2). A biographical questionnaire 3). The Silencing Response Scale

-The compassion fatigue subscale showed that nearly all of the participants were at average to high risk of experiencing compassion fatigue.

Strengths -The results coincided with previous research regarding negative aspects of stress and burnout. Limitations -Small sample size - Did not take into count government employed nurses whom have fewer resources

Level VI

Potter, P. Deshields, T. Divanbeigi, J. Berger, J. Cipriano, D. Norris, L. Olsen, S. 2010 Compassion fatigue and burnout

Descriptive, cross-sectional survey conducted in inpatient nursing cancer units and outpatient cancer clinics. Data collected to assess compassion fatigue, compassion satisfaction, and burnout

153 healthcare providers, 132 RNs, 10 medical assistants, 6 patient care techs, 5 x-ray techs. Study assessed the participants age, years in health care, and years in oncology

1). The 4th revision of the 30-item Professional Quality of Life (ProQOL R-IV) scale.

Study showed Burnout score was 21.5% amongst the participants, compassion fatigue was 15.2%. Findings showed ⇑risk for compassion fatigue included- 11-20 years of healthcare experience (Potter et al., 2010).

Strengths - As a result of the a program is in the process of being instituted to reduce compassion fatigue. Limitations - Small sample size, -study was one-time cross-sectional study.

Level VI

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Nicholson, J. Slade, P. Fletcher, J (2010) Termination of pregnancy services: experiences of gynaecological nurses

Study was to identify the experiences of gynecological nurses involved with termination of pregnancy. Study was a qualitative and quantitative study.

Seven nurses, who work with patients who terminate their pregnancies. Average age of the participants was 43 & they work in the public sector of the UK

Interpretative Phenomenological Analysis (IPA), to interpret individuals’ personal perceptions Quantitative Questionnaires were 1) The Experience of Terminations Survey, 2) The Jefferson Scale of Physician Empathy 3) The Professional

- Participants scored high levels of empathy, average compassion satisfaction, and average scores for compassion fatigue and burnout. Three themes were coded from the participant’s interviews 1). Coping, 2). Strains 3). Contextual influences.

Strengths -Findings support that nursing staff should discuss and reflect upon their feelings. Limitations -The research article explained the results of the qualitative data, but did not go into detail the results of the quantitative questionnaires.

Level VI

Abendroth and Flannery’s (2006) study was a non-experimental descriptive

design that utilized cross-sectional data with descriptive and inferential statistics to

investigate the relationship between nurse traits and compassion fatigue risk. The study

was conducted on 216 nurses from 22 hospices across the state of Florida. Their target

population was registered nurses (RNs), advanced registered nurse practitioners

(ARNPs), and licensed practical nurses (LPNs). The inclusion criteria were that the

nurses had to be over 18 years old, employed by a Florida hospice organization, and they

had to provide direct patient care. Nurses were excluded from the study if they did not

work in an inpatient hospice facility, home care, or hospice admissions (Abendroth &

Flannery, 2006). Two instruments were utilized to conduct their study. The first was an

original survey developed to collect participants’ demographic data. The second was the

Professional Quality of Life Scale: Compassion Satisfaction, Burnout & Compassion

Fatigue/Secondary Trauma (ProQOL-CSF), which assesses the risk of compassion

fatigue (Stamm, 2005). The ProQOL-CSF is currently in its 5th rendition (Stamm, 2010).

Abendroth and Flannery used the 3rd revision of the ProQOL (2006).

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Elkonin and van der Vyver’s study employed a quantitative exploratory-

descriptive design to describe the work-related positive and negative emotions

experienced by ICU nurses. Qualitative data were obtained utilizing three collected

surveys (Elkonin & van der Vyver, 2011). The study was conducted in East London at

three ICUs with a total of 75 nurses. The inclusion criteria were nurses with a minimum

of six months of ICU experience who could comprehend English. No exclusion criteria

were set based on demographics with the exception of the questionnaire only being

provided in the English language. Elkonin and Van der Vyver (2011) utilized the fourth

edition of the ProQOL R-IV, a biological questionnaire, and the Silencing Response

Scale for their study. The biological questionnaire asked participants to detail their age,

gender, language, qualifications, years of nursing experience, and years of intensive care

nursing experience. The scale comprises 15 statements on a scale of “rarely”, “never,”

and “always” to screen participants for a silencing response, a coping mechanism that

health care workers use to avoid listening to patients’ traumatic experiences.

The Potter et al. (2010) study was a descriptive, cross-sectional survey conducted

in inpatient nursing cancer units and outpatient cancer clinics. Data were collected to

assess for compassion fatigue, compassion satisfaction, and burnout. Potter et al. (2010)

studied 153 healthcare providers, 132 RNs, 10 medical assistants, six patient care

technicians, and five radiology technicians. The study assessed participants’ age, years of

experience in health care, and years of experience in oncology. The study was conducted

at a Cancer hospital in the Midwestern US and included five inpatient oncology units,

four outpatient cancer clinics, and three physician-run clinics. The inclusion criteria were

that participants had to work in the designated oncology units and could be RNs, patient

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care technicians, medical assistants, and radiation therapy technologists. No exclusion

criteria were noted. Potter et. al (2010) also utilized the fourth edition of the ProQOL for

their study of oncology nurses at risk for compassion fatigue. The ProQOL –R-IV

measures predictions of participants’ risk for compassion fatigue and burnout and can

measure the positive aspects of caring for traumatized patients and compassion

satisfaction. The survey is broken down into 30 questions and is scored on a six-point

Likert scale.

Nicholson et al.’s (2010) study utilized a mixed methods design to identify the

experiences of gynecological nurses involved with pregnancy terminations. The study

included seven nurses who worked with patients that received abortions for medical and

non-medical purposes. Participants worked at a public sector service in England. The

inclusion criteria were that participants be RNs and permanent employees. No exclusion

criteria were included.

Nicholson et al. (2010) utilized the interpretative phenomenological analysis

(IPA) to interpret individuals’ personal perceptions from a qualitative perspective.

Quantitative questionnaires employed were 1) the Experience of Terminations Survey, 2)

the Jefferson Scale of Physician Empathy, and 3) the Professional Quality of Life Scale.

The Experience of Terminations Survey was developed by the researchers to collect

statistics on participants’ involvement with pregnancy terminations. The Jefferson Scale

of Physician Empathy is used to measure a health care worker’s compassion (Nicholson

et al., 2010).

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Level of Evidence

All four research articles are considered Level VI on the evidence hierarchy pyramid.

There are seven levels of evidence and they are ranked against each other according to

their research effectiveness. Level I is considered the highest-ranking level of evidence. It

is consistent with systematic reviews of randomized controlled and nonrandomized trials.

A meta-analysis is used to review all research studies applicable to the research topic. By

gathering data from all of the previous studies, a consensus can be made.

Level II of the evidence hierarchy pyramid consists of single randomized

controlled trials and single nonrandomized trials. Participants in randomized controlled

trials are selected at random to participate in multiple treatment groups for one study

(Polit & Beck, 2012), whereas nonrandomized trials allocate study participants in

multiple nonrandom treatment groups. Level III is based on retrospective cohort studies

(Ho, Peterson, & Masoudi, 2008), which are conducted over time with a purpose of

evaluating participants for potential risk factors of a disease or illness. Retrospective

cohort studies are less expensive and take less time to research. Researchers are able to

gather data and screen for similarities, or risk factors, on a large group of individuals with

the same illness.

Level IV describes single correlational or observational studies. Correlational

studies are based on affiliations between two associations or variables (Polit & Beck,

2012). The researcher observes subjects over time and reviews the data prospectively or

retrospectively (Ho, et al., 2008). Cross-sectional studies are in the Level V category,

meaning they can measure outcomes and exposures at the same time. They are less

expensive and can be completed in shorter duration than other studies. Level V studies do

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not have the capability to distinguish the results in a temporal sequence, but they are the

foundation for more conclusive studies (Ho et al., 2008).

Level VI contains single descriptive, qualitative, physiologic studies (Polit &

Beck, 2012). They are inexpensive and accommodating, but it is difficult to confirm the

incidence and prevalence of the findings (Ho et al., 2008). Level VII studies are the

beliefs of authority experts (Polit & Beck, 2012).

Summary

All four studies used the ProQOL as part of their instrumentation (Stamm, 2005);

however, different editions were utilized. The Professional Quality of Life Elements,

Theory, and Measurement website (2010) states that the ProQOL is currently the most

widely distributed survey to assess compassion fatigue, burnout, and compassion

satisfaction simultaneously. The website allows researchers to use the questionnaire for

free as long as the author is cited and the survey is not edited in any way (Stamm, 2010).

Conceptual Framework

The nursing theory that ties into compassion fatigue is Martha Rogers’ Science of

Unitary Human Beings (SUHB), which illustrates that when two individuals interact

there is an exchange of their energy fields. When a registered nurse cares for a suffering

or traumatized patient, it is essential that the nurse be in a caring state. Intense amounts of

negative energy can be emotionally detrimental for the suffering or traumatized patient. If

a nurse is compassionate and caring, the patient will interpret the energy as positive

energy, and will experience a connection with their nurse (Dunn, 2009).

The principles of Roger’s SUHB theory are learned profession, science, art,

negentropy, energy field, pattern, pandimensional, unitary human being, and environment

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(Malinski, 2009). Watson and Smith expanded on the SUHB (2002) and listed seven

tenets of Rogerian SUHB: energy field, environment, pandimensionality, pattern,

principle of resonancy, principle of integrality, and unitary human beings. Energy Field is

the cohesion of the living and the nonliving. Environment is the energy that human

beings experience with themselves and the environment. Pandimensionality is the fourth

dimension that connects humans with the universe. Pattern is the perception of energy in

a single wave. Principle of resonancy indicates a continuity of energy fields from lower

to higher. Principle of Integrality is the continuity of humans exchanging energy with

their environment. Finally, unitary human beings refers to the ever-changing non-

predictable energy field between people (Watson & Smith, 2002).

Nurses with compassion fatigue may be unable to care for themselves and may

only function as task-oriented individuals (Dunn, 2009). Nurses that are aware of Roger’s

SUHB, however, will make a conscious effort to transfer positive energy to their patients.

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CHAPTER THREE

Methodology

Compassion fatigue in the nursing profession can be detrimental to individual

nurses as well as health care organizations. Nurses that are victims of compassion fatigue

may experience an overabundance of medical and mental health conditions and nurses

working with traumatized and suffering patients may start to relive the patients’ stress

and anxiety (Portnoy, 2011; Figley, 2002). Health care organizations are affected by

compassion fatigue as employees call in sick and experience conflict and lack of

teamwork, and nursing staff resist necessary changes (Smith, 2010). The primary purpose

of this project is to review the evidence on compassion fatigue prevention strategies to

develop a nursing self-care film for RNs.

Program Development

The nursing self-care instructional film, entitled “Development of an Nursing

Education Plan with Compassion Fatigue Preventive Strategies for Registered Nurses,”

will be presented on a Compact Disc Read-Only Memory (CD-ROM). The purpose of

this CD-ROM is to appeal to registered nurses while utilizing the three major learning

styles: visual, auditory, and kinesthetic/tactile. Visual learners prefer to observe

information by viewing pictures, diagrams, handouts, films, & demonstrations, while

auditory learners learn best by listening to an instructor or by sounds and noises.

Kinesthetic/tactile learners learn best by touching, feeling, holding, and using their hands

to understand new material (University of Massachusetts Dartmouth, 2012). This CD-

ROM may primarily appeal to auditory and visual learners; however, while the nurses are

reviewing the educational video they will be asked to complete a self-care plan. The

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process of note taking during the video may engage the kinesthetic learner.

The video contains moving visuals, audio media, and non-projected still visuals

(Billings, & Halstead, 2012). The video begins with a list of objectives and a reporter

discussing the background of compassion fatigue (Appendix A) and then cut to a moving

visual of a registered nurse working on a medical surgical ward during an extremely busy

day (Appendix B). A moving visual is an approach to make a performance seem like a

real situation (Billings, & Halstead, 2012); it provides viewers with multi-sensory

learning environments that may allow them to retain more information (Zhang, Zhou,

Briggs, & Nunamaker, 2006). The moving visual will also have audio media with

scripted dialogue to enhance the moving visuals with sound.

Non-projected visuals are graphic materials that make a statement to the viewer

(Billings & Halstead, 2012). The non-projected still visuals presented throughout this

film will be used to reinforce learning; for example, after the hospital scene, a non-

projected still visual will list the signs and symptoms of compassion fatigue. The video

will continue with a registered nurse dramatizing the signs and symptoms of compassion

fatigue.

This film will be accompanied by a self-care plan handout (Appendix C). It is

hoped that after viewing the film and completing a self-care plan, nurses will be able to:

1) Define compassion fatigue.

2) List the symptoms of compassion fatigue.

3) Discuss the effects of compassion fatigue on patient care and the nursing

profession.

4) Describe treatment modalities for compassion fatigue.

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5) Identify compassion fatigue preventive strategies for registered nurses.

Needs Assessment

A needs assessment will be conducted in the classroom before starting the

educational CD-ROM. The needs assessment will be based on a Classroom Assessment

Technique (CAT) and will be used to identify nurses’ prior knowledge of compassion

fatigue (Billings & Halstead, 2012). Nurses will write a one-minute paper detailing

everything they know about compassion fatigue. The one-minute paper is a valuable

activity because it is brief and can provide direction on any information that will need to

be provided through lecture if not already available in the CD-ROM (Davidson, 2009).

The knowledge gathered from this needs assessment can also help increase the efficacy

of the digital video presentation (Hauer & Quill, 2011).

Student Learning Outcomes

According to Hauer & Quill (2011), learning objectives are statements that

describe skills, knowledge, and attitudes that students should exhibit after a course or

clinical rotation. Similarly, student learning outcomes are desired characteristics that

students will demonstrate after completing a classroom, or a hospital-based course

(Billings & Halstead, 2012). Student learning outcomes provide students with a precise

description of what to expect and what is expected of them during and after the

educational session (Hauer & Quill, 2011). There are four student-learning outcomes for

the compassion fatigue preventive strategies presentation. Following the presentation,

nurses should be able to:

1) Identify five people to call on for emotional support and list these

individuals in the self-care plan.

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2) Define four self-care needs that are necessary to prevent compassion

fatigue.

3) Develop a self-care plan for compassion fatigue prevention on the

provided handout while viewing the video presentation.

4) Describe two self-care needs that are most lacking in participants’

personal lives.

Anticipatory Set

According to Billings & Hallstead (2012), “the anticipatory set is the creation of

an environment that ignites students to be interested in the subject material” (p. 263). The

anticipatory set should not take a great deal of time and should set the stage for

progressive participation. For this presentation, the anticipatory set will be a video that

precedes the lecture and covers compassion fatigue symptoms and preventive strategies.

The video will have audio and visual dramatizations to engage the learner.

Instructional Strategies

With technology rapidly advancing, nurse educators must have instructional

methods that are current and up to date with the needs of younger students

(Bassendowski, 2007). After determining the learning outcomes and creating the

anticipatory set the teaching strategy is the third process of the lesson plan (Billings &

Halstead, 2012). While developing the instructional strategies the nurse educator must

keep in mind the class size, the amount of time available, and the number of students

(Billings & Halstead, 2012).

Most nurses have minimal time for continued nursing education during their

workday; thus, this presentation is designed to be completed in 25 minutes. The

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instructional strategy is to provide a handout, present the class with a video presentation,

and then follow up with a brief, five-minute lecture designed to answer any questions

(Billings & Halstead, 2012). The handout is a self-care plan that nurses can take notes on

during the presentation; according to DeYoung’s (2009) recommendation, it will be

clean, precise and easy to read.

Program Delivery

The teaching presentation is set to take place in September 2013 at a hospital in

Southern California. Participants will be nursing staff assigned in all specialty areas of

the hospital. Due to scheduling constraints, the presentation will be given to groups of 5-

10 nurses. The teaching site has several classrooms dedicated to education and training.

Each classroom is equipped with overhead projectors and technology to display visual

media. Additionally, all classrooms have sufficient tables and adequate seating to

accommodate participants in this presentation. In the event that a classroom is

unavailable, the presentation can be given in a conference room and the film can be

shown on a personal laptop computer.

The presentation will begin with an introduction of the facilitator’s full name and

credentials. The nurse participants will then receive a handout with the outline of the CD-

ROM and a self-care plan and a blank sheet of paper. Next, the participants will complete

a needs assessment by writing a one-minute paper about their knowledge of compassion

fatigue. While participants are watching the CD-ROM, the facilitator will review the one-

minute papers. If there are questions or issues not covered by the CD-ROM, the

facilitator will discuss them following the film. Finally, participants will complete an

additional one-minute paper and take a post-test to assess and evaluate learning as a result

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of the presentation. The assessment and evaluation process will be discussed in Chapter

Four.

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CHAPTER FOUR

Evaluation

Nurses caring daily for suffering and traumatized patients may encounter

compassion fatigue with repeated exposure. Risk factors for compassion fatigue can

include responding to life-threatening emergencies and a lack of support groups to

debrief intense situations. There are five categories available for identifying and assessing

compassion fatigue: 1) affective states in the helper, 2) cognitive expectations with

individual capacities to process information, 3) ego-defensive processes, 4) stress effects

on the helper’s self-capacities and ideological beliefs, and 5) coping abilities and

techniques of stress management (Boyle, 2011).

Nurse compassion fatigue can be managed with promotion of prevention,

assessment, and treatment strategies (Boyle, 2011). The purpose of this project was to

develop an educational plan to prevent compassion fatigue. Prevention strategies of the

educational plan emphasize the importance of one’s physical, social, emotional, and

spiritual needs (GCAT, 2010).

Evaluation Framework

The tool chosen to evaluate compassion fatigue preventive strategies is

Kirkpatrick’s Evaluation Framework, which has four levels in the framework model: 1)

reaction, 2) learning, 3) behavior, and 4) results. Reaction describes the evaluation of the

overall course in regards to the setting, supplies, facilitator, and educational projects. The

Southern California hospital has a standardized training critique form that is utilized for

most courses. The training critique evaluation will be given out to assess the nurses’

reactions to the setting and overall impression of the course (Hambleton, n.d.). Appendix

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D). Level two of the framework determines whether learning took place. Learning will

be evaluated by assessing participants’ answers on a post-test. Level three, behavior,

evaluates whether the new knowledge has been applied to the job. This is done by

observing the nurses and verifying that self-care plans are completed after the

presentation. Level four evaluates the results on a long-term basis (Rouse, 2011), which

requires an Institutional Review Board (IRB). The next step will require nurse volunteers

to fill out the ProQOL Trauma Scale Survey prior to viewing the presentation and again

three months post-presentation. The data collected from the pre- and post-survey will

determine whether level four was met and whether risk for compassion fatigue decreased,

increased, or stayed the same after viewing the educational film.

The data collection plan consists of disseminating a command-wide email

requesting nurse volunteers to participate in the study. The nurse participants would be

challenged with completing the ProQOL survey, viewing the presentation, and then

completing the ProQOL survey again three months later. One month is required for

recruitment to ensure that enough participants volunteer for the data collection.

The recruiting plan consists of sending out hospital-wide emails weekly for four

weeks and posting flyers in all nursing break rooms (Polit & Beck, 2012). Upon

completion of soliciting for nurse participants, a 60-day window is needed for data

collection. The researcher is responsible for data collection, and the goal is to

accommodate the participants at all cost. The data collection instrument will be the

ProQOL Compassion Satisfaction and Compassion Fatigue Version V Survey (Polit &

Beck, 2012), which has proven to have reliability and validity in research. According to

Stamm (2010), of 100 published studies that screened for compassion fatigue, 50 utilized

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the ProQOL.

After the data is collected, the surveys will need to be scored. The ProQOL survey

has exact directions on how to calculate scores and recommends using Statistical Package

for the Social Services (SPSS) computer software (Stamm, 2010). This researcher will

contact the Head of Nursing Research and Analysis at a Southern California Hospital for

assistance with SPSS. After data analysis, the question of whether or not the educational

plan decreased the risk for compassion fatigue will be addressed.

Assessment

Assessment is feedback based on evidence that learning has occurred, whether

directly or from an indirect method such as a survey of the students’ impressions of the

course (Hernon & Dugan, 2009). In order for an assessment to be measurable, the student

learning outcomes must be concise and precise (McCroskey, 2007). Nurse participants

will be asked to write a second one-minute paper to reflect on what they learned during

the video presentation and lecture (Hernon & Dugan, 2009). The paper will be utilized to

compare the pre- and post-CAT to assess the educational plan and execution (Hernon &

Dugan, 2009). The pre- and post-CAT of a one-minute paper will be reviewed after the

presentation. A custom-made tool will be utilized to determine strengths and weaknesses

of the presentation (Appendix E).

Evaluation

Evaluation is an important tool to determine whether or not students met the

desired learning outcomes (MacNeil, 2007). Rather than a paper post-test, the researcher

will employ an individual response system utilizing white boards for evaluation

(Hainline, Gaines, Feather, Padilla, & Terry, 2010). The post-test will be displayed on

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four PowerPoint slides and participants will write their answers on the white board and

hold it up for the facilitator to see. There are also personal response systems that allow

students to use remote transmitters, or clickers, to answer post-test questions (Gray &

Steer, 2012). These systems were not chosen due to cost constraints.

An alternative to a personal response system is a classroom response system, in

which participants use their personal cell phones to respond to post-test questions via the

Poll Everywhere website (Cornell, 2012). This response method was not chosen because

there is no cell phone reception at the lecture site.

An interchangeable term that applies to the use of clickers to evaluate course

material is the Audience Response System (ARS; (Porter & Tousman, 2010). As of 2010,

seven research studies evaluated students’ opinions of ARS as a tool to evaluate their

learning outcomes. Students in all seven research studies felt more engaged during

lecture and had more confidence to ask questions during lectures (Porter & Tousman,

2010).

None of those seven studies pertained to nursing education. However, in

Southwest Virginia, 24 nursing students participated in an exploratory descriptive survey

to evaluate the effectiveness of an ARS. Three common themes were discovered during

the data collection: 1) students felt they had a better understanding of the course, 2)

students felt more prepared for their national licensure exam, and 3) students paid more

attention and participated more in class (Porter & Tousman, 2010); Appendix F).

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CHAPTER FIVE

Discussion

According to Lombardo & Eyre (2011), there are over 3.1 million registered

nurses working in the US health care industry. Compassion fatigue can be detrimental to

these nurses personally and professionally, and it can be very costly for hospitals due to

high job turnover rates. Work-related symptoms of compassion fatigue are; avoidance or

dread of working with certain patients, reduction in empathy, and lack of joy. The

documented physical symptoms are headaches, digestive problems, muscle tension, sleep

disturbances, fatigue, and cardiac symptoms. Emotional symptoms of compassion fatigue

can include mood swings, restlessness, irritability, anxiety, depression, anger, memory

issues, and poor concentration (Lombardo & Eyre, 2011).

Global Effects

Compassion fatigue and nursing burnout affect the nursing profession globally. In

New Zealand, mental health nurses started a support group to combat compassion fatigue

(Brankin, 2010).

In Turkey, a cross-sectional survey was used to assess burnout in 57 nurses employed

in stem cell transplantation units (Akkuş, Karacan, Göker, & Aksu, 2010). The study

findings were that the burnout rate was higher for older nurses and those who had a

longer duration at their job (Akkuş, et al., 2010). The authors suggested that prevention

for burnout is necessary for nurses who work in the stem cell transplantation unit for long

durations (Akkuş, et al., 2010).

In Ireland, a mixed methods longitudinal study analyzed how coping skills

affected compassion fatigue and burnout in mental health workers and nurses caring for

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the Omagh bombing victims (Collins & Long, 2003a). The researchers utilized the

compassion satisfaction/fatigue self-test to assess participants’ burnout, compassion

satisfaction, and compassion fatigue. The self-test instrument was the first version of the

Professional Quality of Life Scale: Compassion Satisfaction, Burnout & Compassion

Fatigue/Secondary Trauma, originally created by Figley in 1995 (B. Stamm, 2005).

The researchers also utilized the Life Status Review (LSR) to evaluate 30

personal items in the participants’ personal lives. Their aim was to complete a 3-year

longitudinal study of 13 health care workers on a trauma and recovery team that assisted

the more than 650 victims of the 1998 Omagh bombing. The participants all completed

the surveys in August 1998, at which time none were at risk for burnout, and 92.4% had

extremely low risk for compassion fatigue. However, when participants were evaluated

for the third time a year into the study, 38.4% were at extremely high risk for compassion

fatigue. By February 2001, the risk factor for compassion fatigue was reduced to 30.8%

(Collins & Long, 2003a).

In Portugal, a systematic review was conducted to evaluate whether nursing

burnout levels were higher in palliative care (Martins-Perira, 2011).

The study results led researchers to conclude that nurses working in palliative care do not

appear to have a higher risk for burnout than other nursing specialties.

Finally, the United States Navy conducted a quantitative, cross-sectional survey to

identify how burnout was experienced by military mental health professionals in

comparison to the general US population (Ballenger-Browning, 2011). The researchers

used the Maslach Burnout Inventory-Human Services instrument. The findings suggested

that higher burnout predictions were more prominent in female psychiatrists who work

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longer hours and treat patients with personality disorders (Ballenger-Browning et. al,

2011). The researchers also concluded that military mental health providers were less

burned out than civilian mental health providers. The hypothesis was that burnout would

be much higher in providers caring for PTSD patients, but the evidence did not support

that hypothesis (Ballenger-Browning, 2011).

Program Significance

Nurses with compassion fatigue may be overwhelmed with empathy and are often

preoccupied with their patients’ medical and emotional conditions (Stevens-Guille, 2003;

Stewart, 2009). Compassion fatigue increases a nurse’s risk for emotional and physical

illness and affects organizations due to increased sick calls and poor morale on hospital

units. Self-care techniques are necessary to help nurses learn to prevent compassion

fatigue (Stewart, 2009). In North Carolina, for example, a psychiatric mental health

clinical nurse specialist teaches new registered nurses compassion fatigue and self-care

techniques to help them care for their psychological well-being (Lee Walton & Alvarez,

2010).

The film “Development of an Nursing Education Plan with Compassion Fatigue

Preventive Strategies for Registered Nurses” discusses the importance of self-care

techniques. The video describes the importance of caring for one’s physical, social,

emotional, and spiritual needs. The video also reviews important leisure activities. The

overall goal of the film presentation is to promote self-care and wellness for registered

nurses.

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Study Limitations

The original purpose of this project was to conduct a review of the literature on

mental health nurses and compassion fatigue; however, there is currently not enough data

available to determine which nursing specialty is most at risk for compassion fatigue.

Burnout in nursing professionals is 40% higher than in any other medical profession. The

literature indicates that oncology, mental health, emergency room, and critical care nurses

have a preponderance for nursing burnout (Alexander, 2009).

A cross sectional, point-in-time survey was conducted from March to June 2008

to measure compassion fatigue, burnout, and compassion satisfaction in oncology,

nephrology, emergency department, and intensive care nurses in the Southeast US. The

results were not statistically significant for compassion fatigue between the different

specialties (Hooper, et al., 2010). Further research is necessary to evaluate which nursing

specialty is most affected by compassion fatigue.

Additional limitations are based on the educational plan implementation.

Although the educational plan has been developed, it has not yet been implemented;

therefore, process improvement measures, as detailed through assessments and

evaluations, may need to be taken.

Conclusion

Compassion fatigue was defined by Figley (1995) as “a natural consequence of

working with people who have experienced extremely stressful events. Symptoms

include behaviors and emotions resulting from knowledge about a traumatizing event

experienced by another. It is the stress resulting from helping or wanting to help a

traumatized or suffering person” (p. 223). In Texas, a hospital educational program was

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 31

created to prevent compassion fatigue amongst hospital nurses and providers. The

program, which is provided every month during the hospital’s monthly meeting, teaches

nurses and health care providers to develop an individualized self-care plan. The program

was well received by hospital employees and will be incorporated into new employee

orientation (Coe & Spreeman, 2010).

Self-care educational plans should be taught to nurses in all health care

organizations (Stewart, 2009). With the implementation of an effective nursing

educational plan, fewer nurses may develop compassion fatigue.

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Appendix A

Project Film Outline

Objectives

Define compassion fatigue.

List the Symptoms of Compassion Fatigue.

Discuss the Effects on the Nursing Profession as well as Patient Care.

Describe Treatment Modalities for Compassion Fatigue.

Identify Compassion Fatigue Preventive Strategies for Registered Nurses.

Disclaimer- Music with the following words • The material presented in this educational presentation was completed by a student at

Point Loma Nazarene University studying for a degree in Master’s of Science and Nursing. The views expressed in this thesis film presentation are those of the author and do not reflect the official policy or position of the Department of the Navy, Department of Defense, the U.S. Government, nor Point Loma Nazarene University.

Vignette One • Setting – a coffee shop sitting outside away from the customers- wearing

business/casual clothing. I will have a cup of coffee and laptop as a prop. • Introduction- “Hello my name is Phyllis and I have been a registered nurse for nine years. Today

I would like to discuss Compassion Fatigue Preventive Strategies for registered nurses. For starters I would like to give a little background about compassion fatigue.”

What is Compassion Fatigue?

Vignette One

• “Compassion fatigue is a state of captivation with traumatized patients amongst

health care providers, which in turn leads to the health care provider vicariously re-living the patient's trauma (C. Figley, 1995). Compassion fatigue is similar to burnout, but the symptoms appear instantaneously and are more prevalent than burnout. Compassion fatigue is an experience that becomes apparent unexpectedly and causes a sense of despair and bewilderment (Potter et al., 2010). Nurses with

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burnout exhibit a reduction in empathy, whereas nurses with compassion fatigue are overwhelmed with empathy (Stevens-Guille, 2003).

• Insert photo of nursing professionals. • An adequate way to determine if a person is suffering from compassion fatigue or

burnout is to ask one simple question. The question is: “Do you love your work?” If the individual, undergoing a screening for compassion fatigue versus burnout, answers “yes” then they may have compassion fatigue. If the individual answers “no” then they may be suffering from burnout (C. Figley & Figley, 2007).’’

Nursing Risk Factors for Compassion Fatigue

Vignette One • “Most nurses enter the nursing profession to provide nurturing care to patients who

are traumatized or suffering. Nurses in all patient care specialties provide passionate care and attend to the patient’s physical, emotional, and spiritual needs (Lombardo & Eyre, 2011). Nurses are more susceptible for compassion fatigue because of their empathetic emotions to a patient that is in pain, suffering, or who has undergone a traumatic experience (Sabo, 2011). Emergency Department Nurses take care of life-threatening emergencies for patients that are experiencing trauma, chronic obstructive pulmonary disease, heart attacks, and various other unstable conditions (ASOR, 2007).

• Emergency department nurses have an extremely stressful job position, and are at

high risk for compassion fatigue. Operating Room (O.R.) nurses are at an increased risk for compassion fatigue because one moment they are in a calm serene environment in the O.R., and the next minute a patient’s blood is spilling on the floor and nursing tasks need to be completed extremely fast in order to save the patient’s life (Kendall, 1998). Mental Health nurses are also at an increased risk for compassion fatigue because they vicariously re-live the patient’s trauma (Kendall, 1998). All nursing specialties are at risk for compassion fatigue related to nurses continuously witnessing patients suffer.” Further research is needed to evaluate which nursing specialty is most affected by compassion fatigue. Lack of support groups, to process the emotions from intense situations, can also be a risk factor for compassion fatigue (Boyle, 2011).

Cut to Dramatization • A Day in the Life of a Registered Nurse • Vignette Two (Appendix B).

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Cut to Vignette 3

Nurse Gwen’s house

Vignette 3 • -Setting-Nurse Gwen wakes up the next morning after her shift still wearing her

scrubs from the day before. She is awakened by a nightmare. Her eye make-up is slightly smeared over her face, she is lying on the couch with a bag of chips, and cookies, and a “cocktail or wine glass”. Her cell phone keeps ringing and she will not answer it. Takes a drink of her grape juice. After her phone rings 5 times in a row, she finally answers it and has a dialogue,

• “ No Cindy I am sorry I can’t go to the movies with you. I am sick. Uhh….. I have flu like symptoms. Sorry. Can you believe the hospital’s new policies concerning the Sepsis protocols, the new Foley documentation, and the DNR notes? Gosh! That’s all we hear about is EBP, EBP. Someday they will figure out that we always revert to doing things the way we always have, and always will. I am not feeling too good. I will catch you at work next week. … Yes, I am always sick on my days off. This is a tough flu season. Yea I know it’s June, and flu season ended in the spring… but this flu bug is a dozy”.

Vignette Three -Symptoms of Compassion Fatigue

A Voiceover while filming Nurse Gwen sipping Grape Juice and eating chips & cookies

and laying on the couch • “Excessive blaming • Bottled up emotions • Isolation from others • Receives unusual amount of complaints from others • Voices excessive complaints about administrative functions • Substance abuse used to mask feelings • Compulsive behaviors such as overspending, overeating, gambling, sexual addictions • Poor self-care (i.e., hygiene, appearance) • Legal problems, indebtedness • Recurrent colds • Apathy, sad, no longer finds activities pleasurable • Difficulty concentrating • Mentally and physically tired • In denial about problems • Reoccurrence of nightmares and flashbacks to traumatic event • Chronic physical ailments such as gastrointestinal problems’’.

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(Smith, 2010).

Cut back to Vignette One at the Coffee Shop

Vignette One- Criteria For a Diagnosis • Can be categorized by one or all of the following symptoms: • Re-experiencing traumatic events • Avoidance or numbness of reminders of the traumatic event • Persistent arousal

(Baranowsky & Gentry, 2011).

Vignette One-Effects on Nursing

Compassion Fatigue effects the nursing profession in many ways. • Nurses whom work with suffering and traumatized patients day in and day out may

start to become physically and emotionally drained over time. • Nurses, with compassion fatigue, may also show a decline in job performance, as well

as an increase in nursing mistakes • Nursing morale and personal relationships decline, and nurse’s personal lives begin

to degenerate (Kendall, 1998). • He or she may wish to leave the nursing profession (Hooper, Craig, Janvrin, Wetsel,

& Reimels, 2010)

Vignette One- Effects on Patient Care • High patient satisfaction statistics amongst hospital surveys have coincided with

high levels of nurse caring and compassion (Hooper, et al., 2010) • In order for patients to receive high quality patient care nurses need to have

outstanding nurse leadership, adequate nurse staffing, appropriate genuine relationships with providers, and a safe work environment (Van Bogaert, Meulemans, Clarke, Vermeyen, & Van de Heyning, 2009).

• Improving nurse’s work environment will prevent nurse burnout and compassion

fatigue, and will increase patient satisfaction (Van Bogaert, et al., 2009).

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Vignette One- Treatment for Compassion fatigue “According to Dr. Baranowsky from the Traumatology Institute the major objectives for

compassion fatigue treatment include: understanding the hierarchy of events, ensuring self-care methodologies, identification of available resources, patient boundary-setting skills, and eye movement de-sensitization and reprocessing”.

Vignette One- Preventive Strategies • At this time I would like to discuss Compassion Fatigue Preventive Strategies.

Vignette Four

Student Learning Outcomes for Compassion Fatigue Preventive Strategies for Registered

Nurses

• 1). Upon completion of this presentation, identify, five people that you can call on for

emotional support, and then document it on your self-care plan. • 2). Define four self-care needs that are necessary to prevent Compassion Fatigue. • 3). On your provided handout develop a self-care plan, for compassion fatigue

prevention while viewing the video presentation. • 4). Once this digital video presentation is complete review your provided handout,

and describe two self-care needs that are most lacking in your personal life.

Vignette Four

Casual attire (business casual). Different location- Balboa Park • “The Green Cross Academy of Traumatology has set forth guidelines of self care. The

first purpose for their guidelines is to do no harm to self while caring for others (Green Cross, 2010), and secondly, each health care provider, has to take care of his or her own physical, social, emotional, and spiritual self.’’

Vignette 4 • “Another intervention that can be utilized to ensure physical, social, emotional, and

spiritual well being is to participate in Self-Hypnosis. Self Hypnosis ties into the Mind, Body and Soul aspect of wellness. Self-Hypnosis can lower the heart rate, provide relaxation, and can decrease stress”. (Ruysschaert, 2009).

Physical well being- Vignette Four • “According to the GCAT Every Nurse, or healthcare provider, has a universal right

to wellness. With that being said Physical Rest, Nourishment, Sustenance modulation, Body Works and Self-Hypnosis are all important aspects to ensure that each nurse’s

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physical well being are in tune.” (Green Cross, 2010) Ruysschaert, 2009).

Physical Rest- scene Vignette Five- Amanda’s bedroom • Voiceover- “Every nurse deserves a restful period of sleep away from their

workplace.” (Green Cross, 2010). • While that line is being said, a clip of Amanda (Nurse Gwen) is pulling the covers

under her chin with her room dark with candles (maybe the fake battery operated kind), with soft music in the background and a sleep mask.

Vignette Six- Any FAST Food place- that supersizes the meal! • Voiceover- “Take a look at Nurse Cindy to see how Nourishment, and Sustenance

modulation are essential for her Physical Well Being” • Nurse Cindy is in her whale scrubs and drives through a drive through. She orders • “A Double Cheeseburger, supersize French fries, Large Milkshake…I. apologize

miss…I need to take better care of myself…may I please have the grilled chicken salad with Ice Tea instead?’’

Vignette Seven- The Beach • Nurse Cindy jogging on the beach. Nurse Cindy is wearing exercise clothes. • Voiceover- “Exercise is extremely important for Physical Well Being for Nurses. The

Defense Center of Excellence recommends exercise for military health professionals as a self-care strategy.’’ (DCOE, 2012).

Vignette Eight-Massage Parlor • Voiceover- “Body works, for physical well being, means that each nurse is aware of

his or her body and monitors for any tension areas. After a tension area is discovered he or she will then execute manners on ways to relieve that tension.’’ (Green Cross, 2010).

• Nurse Cindy in her whale scrubs again receiving massage in chair from massage therapist.

Social Needs-cut back to

Vignette four • Holding up the self care plan handout- “It is important that every nurse has a social

support system. On your self-care plan handout list at least 5 people that you can call on for support with at least two of those individuals from your place of employment.” (Green Cross, 2009).

• Social Needs –Vignette Nine- Amanda’s back yard –can

look like a outdoor patio- for work • Voiceover- while filming Gwen and Cindy outside chit chatting. “Social support is

necessary for decreasing burnout and compassion fatigue. Frequent debriefing sessions to discuss stressful incidents can promote resiliency and compassion satisfaction”. (Ruysschaert, 2009).

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Vignette Nine • Nurse Gwen and Nurse Cindy are sitting outside in the patio like in a circle. Cindy

wearing the whale scrubs, and Gwen wearing purple pants with gray long sleeves t-shirt and dark blue scrub top.

• Nurse Cindy: “Yea Gwen, I feel so bad that Mrs. Mowrer passed today. The RRT team came immediately after I talked to you today and she was transferred directly to the ICU and coded there and passed away within 20 minutes of leaving our floor. You know she was laughing and joking and eating breakfast and talking about her plans to see her grandson this weekend and then within an hour she passed away. I just feel so bad, I am in shock.”

• Nurse Gwen: (with a flat affect) “I know what you mean.”

Vignette Ten

Nurse Cindy in car in the driveway- Amanda’s house • Voice over (filming Nurse Cindy pull up in the driveway- a shot of her inside the car-

completing her self-hypnosis, wearing the whale scrubs: “To ensure that each nurse cares for his or her social needs, a written measurable plan to leave work at work and to enjoy leisure activities should be completed and frequently re-evaluated (Green Cross, 2009). Let’s listen to Cindy completing her self-mediation as she practices the “me” and “not me” technique, developed by Dr. Ruysschaert the President of European Society of Hypnosis. Cindy’s goal is to arrive home in her own body and mind.” (Ruysschaert, 2009).

Cindy will turn on the spa satellite radio station and will close her eyes and state • “I am home now, I will be present in this moment, I feel calm, relaxed, I will focus on

work with 100% while at work, and I will focus on home 100% while at home. I am ready to fulfill my role as wife, mother, pet owner and friend. I take this moment to connect my inner self with my outer self. When I get out of my vehicle I am letting go of work and enjoying my personal life. ”

Back to Vignette Four- Emotional Needs • “According to Dr. Charles Figley, and his wife Kathleen Figley, Healthcare

Professionals have a true calling to care for those who are suffering and traumatized. However, ignoring self-care and not being fully cognizant about the risks of caring for others can be emotionally toxic (Figley, C., & Figley, K. 2007).

• Nurses need to ensure that they continuously concentrate on their emotional needs.”

Vignette Four- Emotional needs

With Vignette Eleven- (showing the journals) • “ Journaling can be a solution to battle bottled up emotions. It is believed that

documenting a narrative about a stressful incident can allow the individual to

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understand the ordeal better, and can promote resilience (Horneffer & Chan, 2009). Sandy Grason, a life coach and business mogul wrote that journaling can be a place to document and release your emotions, and can be a way to clear your mind to focus on the present. She stated that some individuals keep different journals for different occasions such as a dream journal, travel journal, or a daily journal. People can use whatever style of journal appeals to them. She also wrote that journaling doesn’t have to be completed every day, but should be utilized as needed.” (Grayson, 2005).

• Show the different style of journals available with footage of writing in the journal.

Vignette Twelve- Emotional Needs

mirror-un mirror technique- Therapist’s Office Voiceover-“Emotional needs can be taken care of by completing the mirror un mirror

technique. In the 1990’s the mirror neurons were discovered at the University of Parma, Italy by

accident. The discovery was made with Macaque monkeys that were wearing brain electrodes. Whenever the monkeys would complete a task the anterior insula and anterior cingulated cortex would light up on the brain scan. Then it was noticed that the same areas of the brain would light up when the Monkeys witnessed the same task being completed. The test was completed on humans with similar results. It was then that the mirror neurons were discovered in humans. These mirror neurons are important for nurses to be aware of due to witnessing patients who are in pain, suffering and are anxious. A emotional response is common when one witnesses a patient that is suffering (Ruysschaert, 2009).”

Emotional needs- Vignette 12- Therapist’s Office- mirror/un mirror • Words on screen- Self-Hypnosis can lower the heart rate, provide relaxation, and can

decrease stress. The mirror -unmirror technique is a self-hypnosis tool that provides the nurse with a self-awareness to “unmirror” their patient’s demeanor (Ruysschaert, 2009).

Emotional needs- Vignette- 12-Therapist’s Office mirror/un mirror • Setting- therapists office • Client- sitting in chair, poor posture, crying, looking down, completely slouched over

completing a adlib about a horrific experience • Therapist (Keynan)…. Offer the client tissue and sit there in your chair slouched over

with a flat affect, with an occasional nod of the head, facial grimace same as the clients.

• Voice over- “It is believed that suffering and pain is simultaneously felt between the patient and the provider due to the mirror-neuron system. Observing and listening to a patient in distress can lead to an un-intentional mirror image of their demeanor. Self- hypnosis can be performed to un mirror the influence of the patient (Ruysschaert, 2009).

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Keynan “un mirrors” the client. By sitting up in chair, relaxing facial muscles, taking

deep breathes, and rolls shoulders back. Voiceover while he un mirrors the client- “I am aware of my surroundings. I am in a

present state, I will make a conscious effort to un mirror my patient’s posture. I will relax and take deep breaths; I will relax my facial muscles. I will utilize my skill of empathy and listening but my mind will remain in the present place.”

Leisure Planning

Vignette Four • “Leisure activities can contribute to Physical, Social, Emotional and Cognitive Health

(Trenberth, 2005). • Dr. Rudnick from the University of Western Ontario lists Leisure activities by • 1. Sports, such as swimming. • 2. Spiritual activities, such as studying the bible. • 3. Play, such as playing chess. • 4.Arts, such as Sculpturing. • 5. Entertainment, such as popular dancing. • 6. Resting, such as watching television. • 7. Other activities, such as raising a pet.

Spiritual Needs-Vignette 13

The Beach- Meditation Voiceover- “Spiritual customs are effective strategies to prevent stress. Dr. Ilene Serlin

wrote a book entitled “Compassion Fatigue and Regeneration Whole Person Psychology Tool Kits. In her book she describes many self-help tools that focus in on the whole person approach of spirituality. She points out the process of imagery, creative and expressive art therapy, music therapy, dance therapy and the process of meditation as some examples for spiritual clarity. (Serlin, 2012)”

Meditation- Vignette 13- The Beach • More voiceover-“I would like to discuss her self-help tool of meditation. Meditation

is a practice that has been used since ancient times. Meditation teaches our brains to be attentive and aware. On page 14 of her book she has instructions on how to meditate. A good way to get started on learning how to meditate is through breathing exercises and mindfulness of attention. During meditation it is important that the mind and body are synchronized and are aware of the present state (Serlin, 2012). Let’s take a look at Cindy as she practices Dr. Serlin’s technique on the beach”.

Meditation Vignette 13- The Beach • Setting- Nurse Cindy in PT Gear from previous filmed scene of running. She is sitting

on a beach towel with a bible next to her with several spirituality books and Dr.

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 49

Serlin’s book. • Voiceover- “Relax on the beach and sit in a position where you are comfortable. Take

notice of your toes in the sand, and where your weight is balanced while you are sitting up. Relax your hands onto your knees. Relax your weight. Surrender your emotions and concerns into the sand. Feel all the tension in your body starting from your head down to your toes. Allow all of the tension to flow into the sand. Allow yourself to slow down your respirations.”

Aromatherapy and Spirituality- Vignette 14/ Vignette 4 • Voiceover- “Aromatherapy has been used since 4000 BC for religious ceremonies.

Frankincense and Myrrh are mentioned in the New Testament and the Old Testament as Holy Anointing Oil. Native Americans used Sage, Cedar wood and Rosewood during their spiritual rituals. The modern day use of Aromatherapy is used for holistic healing and spirituality. (Poran, 1999)”

• Demonstration can be at Vignette 4. Bring different aromatherapy and explain what they are used for.

Closing- Vignette Four • Every nurse has a responsibility to take care of his or her own physical, social, emotional, and spiritual self. Please keep your self-care plan and have an obtainable, measurable goal of how you are going to prevent compassion fatigue in the future. I

would like to thank nurses in all specialty areas for all of your hard work and dedication.

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 50

APPENDIX B

A Day in the Life of a Registered Nurse

Phyllis J. Dykes

INT. MEDICAL SURGICAL /TELEMETRY WARD - DAY FADE IN:

Reveal NURSE GWEN standing in the middle the ward

receiving report from the nightshift in hand.

She glances at the last few lines of the report, and begins

to move towards the entrance of Bed B. She in intercepted

by DR. JONES.

DR. JONES

Why hasn’t Mr. Dale in Bed C received his blood transfusion yet?

NURSE GWEN

Well Sir, I just received a report that the blood bank was practically out of the blood and

they were expecting an emergency shipment this morning. Apparently most of their

blood expired yesterday, and the entire city is short due to people not donating. I was

going to

check in with all of patients first, and then go down to the blood bank and get that going.

DR. JONES

Well, I am extremely disappointed. A blood transfusion is a procedure

for a medical surgical ward, and that is poor care for Mr. Dale. His Hemoglobin was 7

yesterday. Please, please, get that blood transfusion going right away. I hate to think what

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 51

his hemoglobin is now. If he doesn’t get that blood transfusion STAT he will probably

need to go to

the ICU, and his insurance will not pay for the ICU visit because he

should have not been sent to the ICU for a routine blood transfusion

for MDS.

NURSE GWEN

Yes Sir, on my way!

Nurse Gwen redirects her course to head toward Bed C. She

gets a few steps before she is interrupted again.

TAMMY

(Yelling across the ward)

Nurse Gwen!

Nurse Gwen turns to look at her.

Reveal TAMMY approaches Nurse Gwen in the middle of the

ward.

TAMMY

They need Bed B in the cath lab right away!

Nurse Gwen nods and proceeds past Tammy and approaches the

WARD CLERK.

NURSE GWEN

I am on my way to drop off Mr. Sena at the cath lab, and then I will

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 52

pick up the blood at the blood bank and get the blood transfusion

started right away.

Nurse Gwen heads toward Bed B to start getting Mr. Sena

ready for transport.

The wife of the patient in Bed A comes out in a yellow

isolation gown and starts when she sees Nurse Gwen.

WIFE

Hi there Gwen! It’s nice to see you.

Gwen stops her action and turns around towards the source of

the voice.

WIFE CONT.

We missed you the last couple of days. We liked our nurses the last couple of days, but

we definitely missed you. Can you come in and help me clean up my husband? He

still has C-Diff you know.

NURSE GWEN

Sure no problem, I will be right in.

Nurse Gwen begins looking around for any other Nurses. She

doesn’t see any and approaches Tammy at the nurses station

to inquire as to why.

NURSE GWEN

Um...Tammy? Where are LaKesha and Valentina and Cindy? I thought that

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 53

LaKesha was charge nurse today, where is she? And where is Carol our CNA?

TAMMY

LaKesha is off the ward taking her patient to MRI; an RN had to go

because he had to be sedated because of his severe anxiety.

Valentina’s patient had an RRT during the night shift and she is

transferring him to the ICU. Cindy is in Bed F with Mrs. Mowrer. She

just rang her call bell and said she is having chest pain 10/10. And

oh, Carol just started having contractions and she went up to the labor deck.

NURSE GWEN

Okay, I will help clean up Mr. Arnold real quick in Bed A, and

then grad the cardiac monitor so I can run Mr. Sena down to the

cardiac cath lab and then stop by the blood bank and pick up Mr.

Dale’s blood and come back and start the transfusion. I got this

Tammy!

She rushes over to cabinet that contains isolation gowns.

Nurse Cyndi comes out of Bed F and approaches Nurse Gwen as

she is in the middle of donning her isolation gown.

NURSE CYNDI

Hi Gwen. Mrs. Mowrer is having chest pain 10/10 and she needs cardiac enzymes stat,

and she said that you were the only nurse that could get her blood with one stick.

She is refusing to let me or anyone else try. She said that only you could get her blood.

NURSE GWEN

Come on Cyndi, you know that I’m not the best nurse on the ward for

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 54

hard sticks. That was a fluke that day. I’m ok at drawing blood, but

you’re much better than me.

NURSE CYNDI

Girl, she won’t even let me look, she said she only trusts you to do

it. Could you please help?

NURSE GWEN

Cyndi, I have several things I already have to do right now that

need my immediate attention. I have to clean up my patient with C-Diff,

drop off Bed B at the cardiac cath lab, pick up the blood bank for Bed C -

NURSE CYNDI

Look, when my patient started having chest pain I called the RRT,

and tried to put oxygen on her, but the oxygen in the room isn’t

working. So I asked Carol to bring up the portable, but she just went

up to labor and delivery because her water broke -

NURSE GWEN

I could take a look and try to get your cardiac enzymes, but can you

please take Mr. Sena to the cardiac cath lab and pick up the blood for

Mr. Dale? I have all the paperwork signed for pick up.

NURSE GWEN

I would love to help Gwen, but I don’t have time to dedicate to any

other patients right now. I need to move Mrs. Mowrer to a different bed

because she needs oxygen and without a portable tank she has to

be moved to a different room. And! The crash cart is empty because

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 55

they just used it for the RRT, so I have to send Tammy to find a crash

cart from another ward until the SPD brings us a new one.

During this rant, the State Inspectors come in with

clipboards.

Nurse Gwen looks on in total shock, while Nurse Cyndi is

still talking. Despair and bewilderment cloud Nurse Gwen’s

face.

NURSE GWEN

Oh dear, Cyndi. The state

Inspectors are here.

CUT TO BLACK.

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 56

APPENDIX C

Compassion Fatigue Preventive Strategies for Registered Nurses The Green Cross Academy of Traumatology (2010) has set forth guidelines for

self care. The first purpose for their guidelines is to do no harm to self while caring for others. Secondly, each health care provider has a responsibility to take care of his or her own physical, social, emotional, and spiritual self.

A. Physical Needs 1. Physical Rest 2. Nourishment 3. Sustenance Modulation 4. Body Works- (such as exercise or massage therapy) 5. Self-Hypnosis. B. Social Needs 1. Frequent debriefing to discuss stressful situations at work. 2. Have a written measurable plan to leave work at work and enjoy leisure

activities. C. Emotional Needs 1. Journaling. 2. Mirror/Un-Mirror Technique Leisure activities can contribute to Physical, Social, Emotional and Cognitive

Health. Dr. Rudnick from the University of Western Ontario lists Leisure activities by 1. Sports, such as swimming. 2. Spiritual activities, such as studying the bible. 3. Play, such as playing chess. 4. Arts, such as Sculpturing. 5. Entertainment, such as popular dancing. 6. Resting, such as watching television. 7. Other activities, such as raising a pet. D. Spiritual Needs 1. Meditation 2. Aromatherapy 3. Prayer Sections A through D are examples of ways that Physical, Social, Emotional and

Spiritual Needs can be met. Below is a self-care plan that is tailored to meet your needs.

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 57

Self -Care Plan 1). Identify 5 people you can call for emotional support. 1. Co-Worker- 2. Co-Worker 3. 4. 5. 2). Describe at least Three Leisure Activities that you find pleasurable (does not

have to be listed above). 1. 2. 3. 3). Circle two self-care needs that you would like to improve on. Next to your

circle describe how you can make a conscious effort to improve, in that area, within the next two months.

1. Physical 2. Social 3. Emotional 4. Spiritual

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 58

APPENDIX D

Training Critique Form Date: Course Title: Location: Instructor: Evaluator Name:

Please mark an X in the appropriate block on a 1-5 scale where 1= Strongly Disagree, 2 = Mildly Disagree, 3 = No Opinion, 4 = Mildly Agree, 5 = Strongly Agree, on the following items:

INSTRUCTOR EVALUATION 1 2 3 4 5

The instructor has increased or improved my understanding of the

subject.

The instructor appeared to enjoy teaching the course.

The instructor made good use of class time.

The instructor encouraged class participation when appropriate.

The instructor attempted to relate course material to the day-to-day job.

The instructor has good communication skills.

COURSE CONTENT AND COURSE MATERIALS

Course objectives were clearly stated.

The course was of the appropriate length for the material covered.

Course materials were easy to read and understand.

Practice exercises were beneficial.

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 59

COURSE RELEVANCY

Course objectives were relevant and enhanced learning.

Course materials were relevant and enhanced learning.

Class discussion was relevant and enhanced learning.

Knowledge and skills taught in the class were relevant and enhanced

learning.

CLASSROOM ACCOMMODATIONS

The classroom environment was conducive to a good learning experience.

The training equipment (computers, etc.) enhanced learning. PLEASE RATE THE ENTIRE COURSE OVERALL WITH 1 BEING UNSATISFACTORY AND 5

BEING EXCELLENT UNSATISFACTORY SATISFACTORY

EXCELLENT 1 2 3 4 5

COMMENTS ABOUT THE COURSE:

_________________________________________________________________

_________________________________________________________________

COMMENTS FOR THE INSTRUCTOR:

___________________________________________________________________

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 60

APPENDIX E

Assessment of Student Learning: One-Minute Paper Date: Course: Compassion Fatigue Preventive Strategies for Registered Nurses Compare and Contrast the pre and post Classroom Assessment Technique to validate strengths and weakness of the presentation.

Needs Assessment for Compassion Fatigue

Preventive  Strategies One  Minute  Paper

(Prior  to  viewing  film,  and  presentation) Billet Points of Understanding - - - - - - - - - -

Billet  Points  of  Misunderstanding -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐

Post Presentation One  Minute  Paper  (post  Presentation)

Billet Points of Understanding - - - - -

Billet  Points  of  Misunderstanding -­‐ -­‐ -­‐ -­‐ -­‐

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 61

APPENDIX F

Compassion Fatigue Preventive Strategies For Registered Nurses Post-Test

1). Define four self-care needs that are necessary to prevent compassion fatigue. A). Evaluate, assess, diagnose, and implement. B). Eat, pray, love what you do, and travel. C). Read, relax, don’t be a people pleaser, and control your mood. D). Physical, Social, Emotional, and Spiritual needs. 2). Which of the following provides an example of Leisure activities? A). Receiving vaccinations, filing tax returns, and cleaning up after a pet. B). Staying late after work for three hours, folding laundry, and getting an oil change. C). Participating in activities such as: dancing, sports, creative arts and spiritual activities. 3). Determine which of the following are physical symptoms of compassion fatigue? A) Deep Vein Thrombosis with Pulmonary Embolism. B). jaundice, abdominal distension, labored breathing, and orthostatic hypotension. C). uncontrollable movements of voluntary muscle groups, and lip smacking. D). headaches, digestive problems, muscle tension, sleep disturbances, fatigue, and cardiac symptoms. 4). Why is it unethical to neglect self-care? A). It is not unethical to neglect self-care. B). Because it is important to look out for number one.

C). Neglecting self-care can lead to unethical behavior. D). Acceptable self-care prevents harm to patients.

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COMPASSION FATIGUE PREVENTIVE STRATEGIES 62

APPENDIX G

MSN Project Film Permission Slip Phyllis J. Dykes, RN, BSN, PHN

MSN Candidate Point Loma Nazarene University

PERMISSION FORM

Name of Applicant:______________________________________________________________

Mailing Address ______________________________________________________________________ ______________________________________________________________________ City State__________ ZIP ______________ Telephone:________________________Email:_________________________________ Description of Project Film

Author: Phyllis J. Dykes Title of film: Compassion Fatigue Preventive Strategies for Registered Nurses Cinematography: Carly Lambert Directed by: Carly Lambert Producer: Phyllis J. Dykes Place of publication of project: San Diego, CA Completion date: July 2, 2013 Classification of project: [ ] Commercial [ X] Non-profit, government, scholarly, small press Nature of project: [ ] Book/e-book [ ] Worldwide, multi-media [ ] Article [X] Film, Video,

Television, CD-ROM [ ] Non-editorial (calendars, cards, book covers, ads, etc.) [ X] Unpublished report, thesis, dissertation [ ] Website [ ] Exhibition [ ] Re-use [ ] Other use – specify:_________________________ Statement of responsibility: I certify that the above information is correct. I understand that this thesis film is a not-for-profit film and is strictly for educational purposes. I grant authorization to display my personal appearance as a cast member in this film.

Signature of Applicant:___________________________________________Date:______________

Form originated from UNIVERSITY OF CALIFORNIA, BERKELEY (http://bancroft.berkeley.edu/reference/dsu/forms/agreement.pdf)